DISCLAIMER: The cases / examples on this blog have been anonymised to maintain confidentiality of patients. Cases have been acquired from various international hospitals and through other medical colleagues with the intention to teach through case examples.

Saturday, 26 April 2008

I sometimes like to do an article based on ethics. Medicine is not just about trying to make a diagnosis and treating everything that is a problem. Medicine is not just a science project that can be controlled like a laboratory experiment. Medicine is a mix of science, personal interactions, subjective and objective opinions from the doctor, the patient and the family with the abundance of feelings all intermingled.

Ethics is a very important part of medicine and is used perhaps unknowingly all the time when making decisions on how to proceed with patient care.

I have observed that the ethical dilemmas are different in Japan compared to the UK. For example, sometimes patients in Japan do not have the finances to be able to pay for expensive treatments and so on occasion, families will make the decision for the patient which may sometimes lead to an alteration of therapy which may not be what the medical staff would advise or think is appropriate. In the UK, taxation pays completely for the medical system and use of medical services is free at source, and hence, treatments are started if there is a clinical need and the patients and their families do not consider the financial aspects as is done in Japan. However, in the UK, I have said that treatments may be started if there is a clinical need. This is where ethics comes into play because although certain treatments are available, all patients are different, and just because certain investigations and treatments can be done it does not necessarily mean that it is appropriate to do such things either because of the patient's refusal or because of severity of illness, reduced life expectancy, poor quality of life etc...

There is often the saying here of 'All or Nothing' treatment. Either you do everything for the patient or do nothing. I have to say that I really do not agree with such a concept to apply to every patient scenario. Life is not always so black and white-- in fact, life is different shades of grey.

For example, should an elderly patient with a pre-morbid history of severe debilitating chronic disease with profound sepsis and fulminant multiorgan failure with a poor quality of life receive expensive extra-corporeal Polymixin therapy, haemodialysis and receive cardiopulmonary resuscitation when such interventions are very unlikely to cause the patient to survive and moreover, would be unlikely to alter the underlying pathology and importantly, cause more unneccessary discomfort?

There are doctors who might say yes. There would be many who would however say no. This is where ethics comes into the situation. Not everything is so clear cut.

Although haemodialysis removes the toxins from the blood, in the presence of DIC, the use of heparin during dialysis in the treatment of renal failure can worsen bleeding! Haemodialysis is a renal replacement intervention but it does not make the kidneys recover any better! It is purely supportive whilst waiting for the kidney to hopefully recover. However, fulminant renal failure might not recover leaving a patient with an additional chronic diseases and worsening quality of life left on thrice weekly haemodialysis which the patient and their family might not be able to afford. Such therapy might prolong life but might be seen by the patient as inhumane and intolerable. From my observations over the years, doctors frequently forget to consider the end outcome when starting major intervential therapies such as haemodialysis or intubation with ventilation therapy in such patients e.g. terminal lung cancer with respiratory failure.

The great anf famous textbooks show us how to think about symptoms and signs of disease, how to investigate and treat but never about the ethical issues and appropriateness of treatment. For this, the only real textbook is experiencing these situations yourself in the hustle and bustle of daily hospital life. Yes, there are many ethics books available with excellent examples of dealing with difficult issues and I would highly recommend reading such books.

Continuing on, patients with severe sepsis have a very high mortality [over 50% ] in various studies despite optimal treatment. Hence, in such a severe situation, even if there is eventual cardiopulmonary arrest, is it appropriate to perform cardiopulmonary resuscitation? One has to think about the overall outcome. If cardiopulmonary resus is successful, will that stop it from happening again? Will it make the other organs recover? The answer is usually no. One has to consider factors such as cerebral damage of CPR, the potential chronic heart disease resulting from ischaemia of the cardiac arrest, the likelihood of success and I come back to the point once again of Quality of Life.

Many patients with severe chronic disease have a shortened life expectancy and poor quality of life. In the UK, patients are asked directly about whether they would want to be resuscitated rather than asking the family. The family memebers are not the patient and in the UK, they are regarded as separate entities and therefore are not able to make such life and death decisions about the patient unless the patient is a child. On occasion, UK patients will directly state that they do not want to be resuscitated despite the contrary opinion from their relatives. Obviously, if the patient is not confused and not suffering from a psychiatric illness, and is considering such an opinion in a logical, clear way, the doctors have to respect the decision of the patient over that of the relatives. The patient is put first.

However, in Japan, the wishes of the family sometimes over-ride the wishes of the patient and sometimes, the patient is not directly consulted. There is the fear of family members that such discussions might make the patient's mental condition worse and that they will somehow 'die from shock' or that the patient would somehow not want to know their fate. From my experience of direct talking to patients in the UK, I have never experienced such spontaneous death from a discussion about the patient's condition directly with the patient and hence, such thoughts are somewhat unfounded in my opinion. Moreover, doctors siding with family members to avoid informing the patient of the diagnosis is again unfounded. As I have mentioned in a previous blog dealing with ethics, by informing the patient allows family members to be entirely honest with eachother in the final days, weeks or months of terminal illness which has the benefit of bringing family members closer together.

Hence, when we are considering whether to institute a treatment, we need to consider not only the medical problem in front of our eyes, but also the social factors and particularly Quality of Life issues. Doing knee-jerk reactional therapy with the 'Do All Or Nothing' approach is ignoring the Ethical issues which might be in direct conflict of the wishes and the interests of the patient.

Another concern I have about family oriented decisions rather than patient oriented decisions is when family members have a potential vested financial interest to gain from the patient's death. Hence, it is my belief that medical personel should be making the decisions when it comes down to investigating and treating the patient albeit still taking into account the opinion and feelings of the family. However, medical personel can look at the patient and their problems in an independent, unfettered manner to decide just what therapies are appropriate. In doing so, it removes a serious conflict of interest that might potentially exist between the patient and the family members interests.

Palliative care is another area which needs much development in Japan and it is entrenched with ethical issues. I have written on Palliative Care in the past and I see this as a very important arm of medicine. Patients should not be put through pointless operations for cancer that have no hope for prolonging life when the other intervention would be controlling pain and other symptoms to make life as happy and tolerable as possible during the final stages of illness. Using a palliative approach is Not a Failure of the Doctors! Sometimes, diseases can no longer be controlled by 'modern' medicine and pursuing treatments which do not alter the final outcome and cause more pain and suffering is not putting the patients first. Although as medical people it makes us feel better that we have tried our best and shows the family that we are really trying to do everything, the patient can get lost in the mix and it might not be the best for them!

One has to ask what is best? Doing everything to make us and the family feel better at the expense of the patient's feeling both mentally and physically or putting the patient first and using ethics based ideology to decide on whether the patient really wants such treatment and whether it will lead to a favourable outcome. Hence, palliative care is sometimes better than 'full active' treatment as pain, agitation, dyspnoea etc can be controlled through symptomatic measures and medications.

When I started off in medicine I thought that medicine was just about saving people from dying of illnesses. Yes, that principle I still hold true and is the driving force for my love of medicine. However, I learned over the years, that not all patients can be saved from the natural course of their illness and having a humane passage out of this world by using appropriate palliative interventions rather than futile active treatment, is sometimes better than doing everything and still losing the battle with the patient suffering more as a result.

Please remember about ethical issues and think about your patient as a whole being, rather than just a system disease based approach. Please consider....